Analysis Mechanical Problems Reportedly, the punt's outboard motor had a history of intermittent failures. Transom height, the point where the motor is mounted, is 40 cm above the waterline when the punt is empty. However, it was reported that the punt was routinely operated with the deep well 3 cm below the waterline when the punt was returning fully loaded. The proximity of the powerhead to the waterline may have caused water to enter it when the height of the waves increased. The operational problems of over-revving and intermittent failures were consistent with the location of the motor. Following the occurrence, the outboard motor was disassembled and inspected. No internal damage was found. Fuel was found in the fuel lines, fuel pump and fuel filter bowl. Water was found in the float bowls of the middle and lower carburetors. When fresh fuel and a battery were connected, the motor fired up and ran well on all cylinders. The lack of internal damage, combined with the ease of starting with fresh fuel and battery, confirms that the motor was not running, or at least not running at full power, when it was suddenly immersed at the time of the capsize. The fact that the punt was recovered with the outboard motor in the raised position also indicates that the motor was not running. The fuel found in the lines and fuel filter bowl indicated that fuel starvation was not likely. However, this fuel was found to be very stale and it may have contributed to the difficulties experienced with the motor. Stability Review of the hull dimensions, cargo distribution, related draughts and freeboards, shows that the punt had positive intact transverse stability when empty and when fully loaded. There are no regulations that govern the draught (and by extension the freeboard) or trim to which a fishing boat such as this harvesting punt can be safely laden. Consequently, mussel harvesting punts have no load lines and the loading of these vessels is left to the judgement of the operators. In this occurrence, the weight of the load was such that the punt had a remaining freeboard of about 30 cm. Such a freeboard was consistent with a cargo of approximately 5 tonnes, and was sufficient to prevent immersion of the deck edge (gunwale) up to an angle of heel of some 14 in calm water conditions. The location of the filled insulated tote boxes on the centreline of the hull, in conjunction with the symmetrical distribution of the remainder of the cargo of mussel socks to port and starboard, ensured the punt was upright and possessed a positive transverse metacentric height (GMt) of approximately 67 cm.[6] The distribution of the mussel cargo and filled tote boxes meant that only the forward and after ends inside the undecked hull remained unobstructed and clear. Any shipped water would be retained mainly at the ends, where it would be free to flow across the full breadth of the hull. The presence of loose or slack water inside a hull has a detrimental effect on transverse stability, as it causes a virtual rise and fluctuation in the position of a vessel's vertical centre of gravity. In general, this free surface effect is not fully understood by fishermen, and few appreciate the substantial reduction of initial transverse stability when water, just a few inches deep, is shipped and retained onboard. When stability is so reduced, a vessel is more vulnerable to the influences of the prevailing sea conditions. Additional downflooding from intermittent immersion of the gunwale causes the heeling and free surface effects to increase, further reducing transverse stability. The detrimental free surface effect of as little as a 7.5 cm depth of water in the empty spaces fore and aft of the cargo, would reduce the punt's virtual GMt to about 30 cm. In addition, the weight of the water inside the hull would reduce the freeboard so that gunwale immersion would occur at an angle of 12.5 in calm water. The presence of shipped water, combined with the dynamic effects of the vessel's rolling motion, could be expected to cause the punt's cargo to shift transversely on the unobstructed aluminium surface, adversely affecting the punt's transverse stability characteristics. A cargo shift of 10 cm would cause the punt to heel, immersing the gunwale. As more water was shipped, recovery would become progressively retarded and finally impossible, as continuous downflooding would cause the punt to fill and sink. However, the punt did not sink. Sufficient air was trapped in the hull to keep the punt afloat. This suggests that the punt capsized rapidly. Capsizing Sequence The initial gradual reduction and final sudden loss of transverse stability were most likely brought about by the free surface effect of shipped water, downflooding and dynamic rolling energy while the punt was drifting beam-on to the prevailing waves. When the punt encountered waves approximately twice the height of the static loaded freeboard, the rolling motion increased and caused more water to be shipped and retained onboard. The rolling motion in conjunction with the free surface and lubricating effects of the shipped water most likely caused the cargo tote boxes to shift slightly and led to the sudden loss of transverse stability. Use of Personal Flotation Device Under the Canadian Small Fishing Vessel Inspection Regulations, a vessel of the type and length of the harvesting punt is required to carry on board, among other equipment, one approved life jacket for each person on board, one approved lifebuoy fitted with 27 m of line, and one watertight can containing six approved self-igniting flares. In this occurrence, neither person on board was wearing a personal flotation device, and there was no such device on board. The vessel, being under 15 gross tons, was not inspected by TC nor had she been voluntarily offered for inspection. The owner was under no regulatory requirement to have his vessel inspected. The vessel would not have passed inspection, due to the lack of boat safety equipment on board. Another boat was on the scene a few minutes after the accident. However, no survivors were sighted--suggesting that the victims sank rapidly. It is probable that personal flotation devices would have kept the victims afloat until the rescuers arrived. Survival Skills and Marine Safety-related Training Neither of the persons aboard had received marine safety-related training; neither was required to have done so. The Board continues to be concerned with the loss of life associated with the vulnerability of the fishing vessels to marine emergencies.[7] Concerned that crew's lack of marine emergency training reduces their chance of survival in emergencies, in 1992 the Board recommended to TC that the crews of fishing vessels receive formal training in life-saving equipment and survival techniques.[8] The Minister of Transport accepted the Recommendation as an interim measure; TC issued Ship Safety Bulletin No. 6/95 on 7 February 1995, which highlighted the importance of Marine Emergency Duties (MED) training to prepare crews to deal with emergencies. However, as MED training of uncertificated personnel is not covered by regulations, the bulletin reiterated that the onus for this training rests with fishing vessel owners and masters. Following consultation with industry, TC introduced the Crewing Regulations, which came into force in July of 1997. The regulations require that before any member of the ship's compliment has completed six months on board the ship, he/she has to obtain a certificate of successful completion of training in marine emergency duties at a recognized institution. This initiative would meet the intent of the TSB Recommendation. The fishing industry expressed concern that fishers would not be able comply with the training requirement because the demand for training would exceed the capacity of marine schools. Consequently, TC agreed to propose a regulatory amendment to the Crewing Regulations. This amendment would effectively extend by two years the deadline for successful completion of MED training if the fishing vessel does not operate beyond the limits of a fishing voyage Class II. TC anticipates that the proposed regulatory amendment will come into force by early 2001. However, the relevant section of the regulations will not apply to fishers until 30 July 2002. Neither TC nor the Department of Fisheries and Oceans knows the exact number of fishers that require basic safety training to satisfy the Crewing Regulations. However, a number of recognized institutions in eastern Canada report that there is little demand by fishers for basic safety training. These institutions also report that while they could now provide more training sessions, the deadline of 2002 may cause a delay in the demand for training and generate a last-minute rush nearer the deadline. The mussel-harvesting punt was fully loaded with about five tonnes of mussels when her outboard motor failed. The exact cause of the outboard motor failure could not be conclusively determined. The punt had positive intact transverse stability when empty and when fully loaded. The punt drifted broadside to the prevailing waves for about 20 minutes, and shipped water. The free surface effects of the shipped water, a slight shift of cargo and the additional dynamic influences of the wave rolling motions most likely caused the complete loss of righting ability, and the vessel suddenly capsized.Findings as to Causes and Contributing Factors The mussel-harvesting punt was fully loaded with about five tonnes of mussels when her outboard motor failed. The exact cause of the outboard motor failure could not be conclusively determined. The punt had positive intact transverse stability when empty and when fully loaded. The punt drifted broadside to the prevailing waves for about 20 minutes, and shipped water. The free surface effects of the shipped water, a slight shift of cargo and the additional dynamic influences of the wave rolling motions most likely caused the complete loss of righting ability, and the vessel suddenly capsized. Findings as to Risk The two occupants were thrown into the water; neither was wearing a personal flotation device, and there was no such device on board. Both persons drowned. The punt did not have on board the safety equipment required by the Small Fishing Vessel Inspection Regulations. There are no provisions requiring an operator of a small fishing vessel of 60 gross tons or less to have marine safety-related training, and neither of the persons aboard had ever received such training.